Physician Assistants in Family Medicine: A Brief History
Family medicine, as a physician assistant (PA) specialty, cannot be discussed without first understanding the intertwined history of PAs and primary care medicine. Of all medical specialties, the roots of the PA profession are truly grounded in that of primary care. The shortage of generalist medical providers and the expansion of patients with access to care because of the enactment of Medicare and Medicaid ultimately led to the innovative development of this new medical practitioner in the 1960s. The development of the PA profession was an innovative strategy to help solve the problem of an overtaxed health care system that was unable to effectively manage the influx of patients seeking primary medical services. In fact, the University of Washington MEDEX PA program, which was one of the first established PA programs, was specifically developed with the mission of training ex-military corpsmen to become primary care providers in the rural areas of the Northwest.
Physician assistants practicing in primary care medicine have had very dynamic roles and experiences over the course of the profession. Historically, the PA profession was developed with the intent of being able to extend the care offered by the physician by providing health care for simple medical problems, such as uncomplicated upper respiratory infections and musculoskeletal injuries. The intended result was that physicians would have more time in their schedules to provide health care to patients requiring chronic disease management and to evaluate more complicated medical complaints. However, as the PA profession grew and developed, many PAs in primary care started managing the full spectrum of care for acute and complicated medical cases alike.
Although the scope of practice for PAs in primary care has been greatly expanded over the past 50 years, there is a trend toward more PAs practicing in medical or surgical subspecialties. What was once a profession created as a pipeline of providers that would help solve the primary care provider shortage has become a profession that currently only has approximately 30% of its members practicing primary care medicine.
Of the primary care sub-specialties, family medicine encompasses the largest distribution of PAs. According to the 2013 American Academy of Physician Assistants (AAPA) Annual Survey, 23.3% of clinically practicing PAs practice in family medicine with or without urgent care. Although the family medicine predominance within the PA profession is starting to be surpassed by other specialties, such as surgery (26.6% of clinically practicing PAs), there are still a significant proportion of PAs who are practicing family medicine.
History Repeats Itself
With the passage of the Patient Protection and Affordable Care Act (ACA) in 2010, the shortage of primary care providers in the American health care system has again been brought to the forefront. Similar to the 1960s, there has been a rapid influx of patients who have been provided with the ability to afford health care. However, there is a concern about whether there are enough medical providers to provide this access to care. Addressing this concern has brought renewed attention to the field of primary care, along with incentives for practicing primary care medicine. The ACA provides expanded funding for the National Health Service Corps, financial support for the training of primary care providers, and Medicare payment bonuses and improved Medicare physician fee schedules for primary care providers. Historically, the PA profession has always been a profession that is concerned about access to care and one that identifies a need within the health care system and fills that need. Therefore, with the financial incentives for primary care providers being offered by the federal government and with the specific inclusion of PAs as designated primary care providers by the ACA, the interest and practice of primary care medicine by PAs is likely to again expand.
In addition to the historical focus on primary care medicine; PAs also have a rich history of practicing medicine in medically underserved and geographically rural areas. As the profession grew, more and more PAs started practicing in more suburban settings, and there has been less focus on providing health care in medically underserved areas. However, this too may again become the focus of the profession with the increased emphasis on the need for medical providers in these areas and as incentives from the federal government are provided. The renewed emphasis of PAs practicing primary care medicine will likely lead to great diversity in what primary care medicine looks like for PAs in different settings. PAs may practice primary care in any of the following areas:
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Rural: PAs practicing primary care in rural areas are often involved in the full array of health care services and may have a scope of practice more expansive than PAs in other geographic areas. Because specialists are often not easily accessible, rural primary care PAs may treat many disease states or perform many procedures that, in another area, may be referred to a specialist.
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Suburban and urban: PAs practicing primary care in these settings have great variance in their scope of practice. Some PAs may have a similar practice to PAs in rural areas; however, some PAs may be involved more with the coordination of health care, including more specialty referrals.
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Federally Qualified Health Centers (FQHCs): FQHCs receive federal funding to provide comprehensive primary care services to medically underserved areas or populations. Many community health centers (CHCs) meet criteria to be an FQHC. From 2006 to 2010, it was estimated that approximately 10% of patient visits at CHCs were to PAs, and the majority of visits were for chronic disease treatment. CHCs have also significantly increased the utilization of PAs, evidenced by a 61% increase in the number of PAs, nurse practitioners, and certified nurse midwives employed by CHCs. The full spectrum of primary care services provided at FQHCs in addition to the expanded hiring of PAs by CHCs is bound to shape the next generation of PAs.
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Patient-centered medical homes (PCMH): The PCMH is a model of holistic, patient-centered health also emphasizing accessible care committed to quality improvement and safety. Increasingly, PAs will find themselves leading the health care team in PCMHs, thus expanding administrative roles of PAs in primary care. The PCMH model is discussed in more detail later in this chapter.
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Accountable care organizations (ACOs): ACOs are groups of health care providers or hospitals that work together to provide high-quality appropriate care at the right time with a focus on prevention of medical errors and fiduciary responsibility in providing medical care. PAs are vital components of ACOs, and in primary care, this is another setting in which administrative roles may be expanded for PAs.
With the new strategies and models of care that have been and will continue to be developed in medicine, it is evident that PAs in primary care will continue to be needed to fill a void that has been present throughout the history of the profession.
The Specialty of Family Medicine
In 1969, family medicine shifted from the traditional generalist model of medicine to become the 20th medical specialty in the United States. In effect, this shift graduated family medicine to become the newest primary care discipline and the second largest medical specialty in the United States. The specialty of family medicine overlaps pediatrics, general internal medicine, general obstetrics and gynecology, primary care geriatrics, and general psychiatry. Given this overlap, it is easy to understand why family medicine is well known for a traditionally complex and large scope of practice. Family medicine providers are well prepared to manage highly complex illnesses, diseases, and comorbidities and able to collect and interpret a great amount of data. This is fueled by an extensive understanding of organic medicine, behavioral health, and general health care systems, resulting in the provision of effective, patient-centered medical care at the lowest cost to the patient and health care system.
Providing evaluation, treatment, and continuous care for patients from “birth to the grave,” ranging from prenatal care to end-of life care, is inseparable from the family medicine approach to patient care. And to further distinguish family medicine providers from others, family medicine providers are among the only medical specialists who are distributed in the same geographic proportion as the U.S. population. Vital to the particular patient approach shared by family medicine providers are the assurances of patient accessibility to high-quality, evidence-based, and culturally sensitive care.
In their research and exploration of family medicine clinician identity, Carney et al. identified five core domains: (1) patient/family relationship; (2) patient advocacy; (3) career flexibility such as options in building a practice and practice emphasis; (4) balancing the breadth and depth of care given the comprehensive expertise needed to evaluate, treat, and follow patients with a wide array of conditions and illnesses across the lifespan; and (5) the comprehensive nature of patient care and continuity of care. Interestingly, Carney et al. also found that many family medicine providers included the importance of supporting and pursuing social justice as a principal element of family medicine. Above all else, many regard the successful establishment of a strong and effective therapeutic relationship with both patient and family as a pillar of family medicine. Particular to family medicine, the provider–patient relationship spans a patient’s life cycle, continuing beyond treatment or cure, and includes the patient’s family members.
A fundamental concept in family medicine is the understanding that knowledge about a patient’s family is of great importance to develop holistic and effective patient management strategies and treatment plans ; this concept is inherent in the systems approach to primary health care, a hallmark of family medicine. Systems theory highlights the interrelationship between natural and social science in helping the family medicine provider to best understand causes and effects as related to patient presentations and outcomes. Biosciences and social sciences become intertwined into a contextual biopsychosocial framework in which the knowledge of a medical science coupled with the context of each patient’s individual characteristics and qualities, family, and community informs the diagnosis, workup, treatment, and follow-up plan.
Perhaps one of the best ways to describe the family medicine–specific approach to patients is through the well-adopted PCMH model. The PCMH concept was initially introduced in the 1960s by the American Academy of Pediatrics (AAP) to refer to a central location for storing and accessing a pediatric patient’s medical records. In 2002, the AAP expanded the definition to incorporate access to care, continuity of care, comprehensive care and family-centered, compassionate, and culturally sensitive medical care of patients. In 2007, the American Academy of Family Physicians, the AAP, the American College of Physicians, and the American Osteopathic Association developed the Joint Principles of the Patient-Centered Medical Home outlining guiding standards for the more current PCMH model ( Box 25.1 ). The family medicine approach to the PCMH provides for the comprehensive primary care of children, adolescents, and adults, creating partnerships between individual patients and families with their personal primary care providers. At the heart of the model are the principles of quality and safety to better establish primary care clinicians and practices as strong advocates for the well-being of their patients with a goal of optimal, patient-centered outcomes via a strong, compassionate partnership among the patient, clinician, and practice.
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Develop strong relationships with patients.
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Provide first contact and continuity of care.
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Incorporate a clinician-led team-based approach at the practice level, assuming responsibility for the continuous care of patients.
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Adopt a whole-person orientation in which the clinician provides for his or her patient’s health care needs, including but not limited to appropriate referrals and follow-up, throughout the life span and for acute, chronic, preventive, and end-of-life care.
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Ensure coordination and oversight of care throughout complex health care systems using such tools as electronic health records to assist in identifying health care services.
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Provide enhanced access to care by incorporating expanded hours, open scheduling, and various forms of communication (e.g., phone, web based, remote communication, face to face).
Family medicine cannot be simply defined by practice location, condition severity, organ system, or even patient age or gender but rather by the provider–patient relationship, as well as relationships with patients’ families and communities. In their research on core themes in family medicine, Bradner et al. identified five core attributes embraced in family medicine: (1) a deep understanding of whole person dynamics; (2) the fostering of personal growth in patients, including practices to promote behavioral change leading to improved quality of life; (3) humanizing patient experiences within the health care setting; (4) enhanced availability for and open communication with patients; and (5) a natural command of complexity.
Beyond providing for first contact and a continual relationship, another particularly common theme in family medicine is the prevention of and screening for disease, including the appropriate management of patients to prevent chronic disease exacerbations resulting in emergency room visits and hospitalizations. The importance of such an approach cannot be overemphasized. Research supports that regions with more primary care providers also have improved population health with lower health care costs; lower death rates from such illnesses as heart disease, cancer, and strokes; and lower infant mortality rates. And as a signal of the importance of family medicine specifically, the correlation among improved health, treatment outcomes, and lower costs was strongest from family medicine providers. Additionally, evidence supports that family medicine outpatient encounters are equally or more complex than specialty nonprimary care specialty encounters.
Family medicine providers practice a very broad breadth of care while maintaining a strong continuing relationship with patients and patients’ families, bridging the boundaries between well-being and illness. In addition to improved access to care for patients of all ages, strong focus on preventive care, and the early management of illness and disease processes, a family medicine approach is also concerned with reduction of unnecessary referral for specialty services and educating patients how to care for themselves whenever feasible. Patient protective and cost reducing practices include rapid access to care, evidence-based care, preventive care strategies, and limiting unnecessary utilization of diagnostics and unnecessary specialty referrals. The provision of cost-effective care, not only to benefit individual patients but also to benefit the larger health care systems is a common theme among family medicine providers.
Family medicine recognizes the great importance of having knowledge of the whole patient to set the stage for a strong and continuous relationship between patient and clinicians. Such knowledge includes not only past medical and psychiatric histories but also social and financial circumstances. For family medicine providers, more utility is often gained from a medical history than “fishing for labs.” Therefore, one characteristic of the family medicine approach is the incredible importance of garnering a comprehensive and accurate patient history.
The Family Medicine Clinical Rotation
Before and throughout their family medicine clinical rotation, students would be best served to recall that the family medicine specialty is unique among specialty practices, ensuring first contact (for both acute and chronic conditions) continuity care for patients of all ages and genders frequently presenting with complex comorbidity or multimorbidity and ill-defined problems. Many family medicine patients present multiple times each year and with multiple issues, complaints, and concerns at each visit. And the prevalence of patients with not just comorbidity but multimorbidity is increasing. It is the provider’s responsibility to prioritize these problems, orchestrating the visit to ensure that patient needs are met; the student shares this responsibility.
Coordination and integration of complex medical problems and comorbidities coupled with the expertise to manage a wide range of acute, subacute, and chronic conditions in a variety of practice settings is required of family medicine providers. Many family medicine providers even include home visits as part of their practice, identifying connections between environment and illness. Additionally, each patient visit, regardless of reason and setting, is an opportunity for health promotion and disease prevention for both the patient and the patient’s family—an opportunity to prevent future illness; address chronic conditions; and potentially, provide care for other family members present during the visit.
Family medicine clinical rotation students should be knowledgeable about the most common acute and chronic presentations and diagnoses seen in family medicine practices. Given the breadth and comprehensiveness in family medicine, these presentations cover a wide variety of conditions and level of urgency, and students can benefit from using multiple key resources throughout their family medicine clinical rotation. Because the family medicine rotation covers such a wide breadth of patients and conditions, it is important for students to be familiar with both texts that offer in-depth coverage of pediatrics and internal medicine as well as texts that offer more rapid access of information ( Box 25.2 ).
